MEDICARE: MR. LARRY WAYNE JOHNSON C.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	CO2834	CA

General Provider Information

NPI Number	:	1396983888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY WAYNE JOHNSON C.O.

Provider Business Mailing Address
First Line	:	10723 MONTEGO DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-1910
Country	:	US
Telephone Number	:	858-565-2230
Fax Number	:

Provider Business Practice Location Address
First Line	:	9570 RIDGEHAVEN CT
Second Line	:	SUITE C
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1667
Country	:	US
Telephone Number	:	858-278-0518
Fax Number	:	858-278-0323

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	01/22/2009

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